Correlation of esophageal lengths in children with height: application to the Tuttle test without prior esophageal manometry

Indications, methodology, and interpretation of combined esophageal impedance-pH monitoring in children: ESPGHAN EURO-PIG standard protocol

AIM

The aim of the study was to provide an updated position statement from the ESPGHAN European Pediatric Impedance Working Group on different technical aspects such as indications, methodology, and interpretation of multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

Evidence was used where available, but the article is based mainly on expert opinion and consensus.

RESULTS

MII-pH provides more information than simple pH monitoring because reflux detection is not limited to acid reflux. Different companies provide commercialized MII-pH recording systems, making the method widely available and useable in daily clinical practice; however, the technique still has limitations: high cost, limited additional value regarding therapeutic implications, and lack of evidence-based parameters for the assessment of gastroesophageal reflux and symptom association in children.

CONCLUSIONS

MII-pH recording is a promising procedure needing further validation and development to increase its additional benefit over conventional investigation techniques. The added value of the technique regards mainly clinical circumstances in which nonacid or weakly acid reflux may be relevant such as persisting symptoms during antireflux treatment with proton pump inhibitors and feeding-related reflux; and assessing specific discontinuous symptoms thought to be associated with gastroesophageal reflux; and research.

Serum gastrin concentrations in children with primary gastroesophageal reflux and gastroesophageal reflux secondary to cow's milk allergy

PURPOSE

The assessment of the serum gastrin concentrations and the role of enterohormone in children with primary acid gastroesophageal reflux (GER) and GER secondary to cow's milk allergy (CMA).

MATERIALS/METHODS

138 children were diagnosed with pathological acid GER on the basis of pH-metric examination. 76 (28.8%) patients had primary GER and 62 (23.5%) patients had GER secondary to CMA.Serum gastrin concentration (fasting and postprandial) was assessed before treatment and 1 and 2 years after initiation of the therapy.

RESULTS

The children with primary GER had the fasting gastrin concentration 69.46 ± 11.87 μU/ml before treatment, 77.86 ± 26.35 μU/ml after 1 year and 83.78 ± 25.21 μU/ml after 2 years of treatment. The children with GER secondary to CMA had gastrin concentrations 89.61 ± 26.75, 73.17 ± 19.49 and 73.90 ± 20.31 μU/ml respectively. The mean postprandial gastrin concentration after treatment was higher than before treatment in children with both primary and secondary GER. The primary GER group had postprandial gastrin concentration 96.07 ± 33.51 μU/ml before treatment and 116.06 ± 33.95 μU/ml and 118.48 ± 33.96 μU/ml after 1st and 2nd year of therapy respectively. The secondary GER group had postprandial gastrin concentration 85.33 ± 14.12 μU/ml before treatment and 106.55 ± 24.51 μU/ml and 110.36 ± 24.67 μU/ml after 1st and 2nd year of therapy respectively.

CONCLUSIONS

The mean fasting serum gastrin concentrations in patients with primary and secondary GER were similar and mean postprandial concentrations were higher than fasting concentrations in both study groups.

Impact of antisecretory treatment on respiratory symptoms of gastroesophageal reflux disease in children

The effect of antisecretory treatment on extraesophageal symptoms of gastroesophageal reflux disease was evaluated. Seventy-eight children presenting with typical and extraesophageal symptoms of gastroesophageal reflux disease underwent a multichannel intraluminal impedance and pH monitoring (MII/pH). Children with a positive MII/pH were randomly treated with proton pump inhibitors (PPIs) or histamine H(2) -receptor antagonists (H(2) RAs) during 3 months. At the end of the treatment period, all patients were recalled. A second treatment period of 3 months was given to those patients who were not symptom-free after 3 months. Thirty-five of the forty-one (85.4%) children with a pathologic MII/pH presented with extraesophageal symptoms and were treated with PPIs (omeprazole; n:19) or H(2) RAs (ranitidine; n:16) for 12 weeks. After 3 months, 11/19 (57.9%) PPI-treated patients had a complete resolution of symptoms; 6/8 nonresponders were treated with PPI for another 3 months and became all symptom-free. The other two underwent a Nissen fundoplication. Only 5/16 (31.2 %) patients treated with H(2) RAs had a complete resolution of symptoms after 3 months; 1/11 was treated again with H(2) RAs during 3 months, and 10/11 were changed to PPIs. In 3/10, a partial resolution of symptoms was achieved, while in 7/10, a complete remission was obtained (P < 0.05). Antisecretory reflux treatment improves extraesophageal reflux symptoms. The efficacy of PPIs is superior to that of H(2) RAs in these children.

Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age

PURPOSE

The purpose was to compare three methods of predicting the gastric tube insertion length in children 1 month to 17 years of age: age-related, height-based (ARHB); nose-ear-xiphoid (NEX); and nose-ear-mid-umbilicus (NEMU).

DESIGN AND METHODS

The design was a randomized controlled trial. Children were randomly assigned to the ARHB, NEX, or NEMU groups. Tubes placed high were considered to be misplaced.

RESULTS

There were significant differences in percentages of correctly placed tubes, with ARHB and NEMU being more accurate than NEX.

PRACTICE IMPLICATIONS

NEX should no longer be used as a gastric tube insertion-length predictor. Either ARHB or NEMU should be used.

Relationship between sleep and acid gastro-oesophageal reflux in neonates

The aim of the present study was to investigate the impact of gastro-oesophageal acid reflux on sleep in neonates and, reciprocally, the influence of wakefulness (W) and sleep stages on the characteristics of the reflux (including the retrograde bolus migration of oesophageal acid contents). The pH and multichannel intraluminal impedance were measured during nocturnal polysomnography in 25 infants hospitalised for suspicion of gastro-oesophageal reflux. Two groups were constituted according to whether or not the infants displayed gastro-oesophageal reflux (i.e. a reflux group and a control group). There were no differences between the reflux and control groups in terms of sleep duration, sleep structure and sleep state change frequency. Vigilance states significantly influenced the gastro-oesophageal reflux pattern: the occurrence of gastro-oesophageal reflux episodes was greater during W (59 ± 32%) and active sleep (AS; 35 ± 30%) than during quiet sleep (QS; 6 ± 11%), whereas the mean duration of gastro-oesophageal reflux episodes was higher in QS than in W and AS. The percentage of retrograde bolus migrations of distal oesophageal acid content was significantly higher in AS (62 ± 26%) than in W (42 ± 26%) and QS (4.5 ± 9%). In neonates, gastro-oesophageal reflux occurred more frequently during W, whereas the physiological changes associated with sleep state increase the physiopathological impact of the gastro-oesophageal reflux. The duration of oesophagus-acid contact was greater during sleep; AS facilitated the retrograde migration of oesophageal acid content, and QS was characterised by the risk of prolonged acid mucosal contact.

Esophageal impedance monitoring for gastroesophageal reflux

Dual pH-multichannel intraluminal impedance (pH-MII) is a sensitive tool for evaluating overall gastroesophageal reflux disease, and particularly for permitting detection of nonacid reflux events. pH-MII technology is especially useful in the postprandial period or at other times when gastric contents are nonacidic.pH-MII was recently recognized by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as being superior to pH monitoring alone for evaluation of the temporal relation between symptoms and gastroesophageal reflux. In children, pH-MII is useful to correlate symptoms with reflux (particularly nonacid reflux), to quantify reflux during tube feedings and the postprandial period, and to assess efficacy of antireflux therapy. This clinical review is simply an evidence-based overview addressing the indications, limitations, and recommended protocol for the clinical use of pH-MII in children.

Percutaneous endoscopic gastrostomy and gastro-oesophageal reflux in neurologically impaired children

AIM: To investigate the effects of percutaneous endoscopic gastrostomy (PEG) feeding on gastro-oesophageal reflux (GOR) in a group of these children using combined intraluminal pH and multiple intraluminal impedance (pH/MII).

METHODS: Ten neurologically impaired children underwent 12 h combined pH/MII procedures at least 1 d before and at least 12 d after PEG placement.

METHODS: Prior to PEG placement (pre-PEG) a total of 183 GOR episodes were detected, 156 (85.2%) were non-acidic. After PEG placement (post-PEG) a total of 355 episodes were detected, 182 (51.3%) were non-acidic. The total number of distal acid reflux events statistically significantly increased post-PEG placement (pre-PEG total 27, post-PEG total 173, P = 0.028) and the mean distal pH decreased by 1.1 units. The distal reflux index therefore also significantly increased post-PEG [pre-PEG 0.25 (0-2), post-PEG 2.95 (0-40)]. Average proximal pH was lower post-PEG but the within subject difference was not statistically significant (P = 0.058). Median number of non-acid GOR, average reflux height, total acid clearance time and total bolus clearance time were all lower pre-PEG, but not statistically significant.

CONCLUSION: PEG placement increases GOR episodes in neurologically impaired children.

Esophageal impedance in children: symptom-based results

OBJECTIVE

To correlate multiple intraluminal esophageal impedance recording with pH-monitoring with symptoms.

STUDY DESIGN

Symptoms occurring within a 2-minute window of a reflux were considered to be associated with reflux. Analyses were performed in 1- to 6-, 6- to 12-, and >12-months-old patients for crying, pain, cough, and vomiting.

RESULTS

A total of 70 of 225 tracings were discarded. Of 2172 symptoms, 1136 (52%) were reflux-associated (45% acid reflux [AR], 51% weakly AR, 3% alkaline reflux). The strongest reflux-symptom association was found for vomiting. Cough-reflux association was higher in infants than in older children. In older patients, symptom-reflux association was more with AR. Symptoms were associated with proximal reflux in 70% of patients. The symptom index and symptom association probability (SAP) were positive (>50% for symptom index and >95% for SAP) for all refluxes in 83% and 46% of patients and for AR in 49% and 47% of patients, respectively. In 1- to 6-month-old infants, symptom index and SAP were higher for weakly AR than for AR. For crying, SAP was independent of AR or weakly AR. For cough, SAP was positive in one-third of patients, predominantly with AR in 6- to 12-month-old infants and with weakly AR in the other infants.

CONCLUSION

Multiple intraluminal esophageal impedance recording with pH-monitoring doubles the probability of documenting an association between symptoms and reflux compared with pH monitoring. In young infants, symptoms are more frequently associated with weakly AR than with AR.

Disagreement between symptom-reflux association analysis parameters in pediatric gastroesophageal reflux disease investigation

AIM: To assess the agreement within 3 commonly used symptom-reflux association analysis (SAA) parameters investigating gastroesophageal reflux disease (GERD) in infants.

METHODS: Twenty three infants with suspected GERD were included in this study. Symptom index (SI), Symptom sensitivity index (SSI) and symptom association probability (SAP) related to cough and irritability were calculated after 24 h combined pH/multiple intraluminal impedance (MII) monitoring. Through defined cut-off values, SI, SSI and SAP values are differentiated in normal and abnormal, whereas abnormal values point towards gastroesophageal reflux (GER) as the origin of symptoms. We analyzed the correlation and the concordance of the diagnostic classification of these 3 SAA parameters.

RESULTS: Evaluating the GER-irritability association, SI, SSI and SAP showed non-identical classification of normal and abnormal cases in 39.2% of the infants. When irritability was taken as a symptom, there was only a poor inter-parameter association between SI and SSI, and between SI and SAP (Kendall’s tau b = 0.37, P < 0.05; Kendall’s tau b = 0.36, P < 0.05, respectively). Evaluating the GER-cough association, SI, SSI and SAP showed non-identical classification of normal and abnormal cases in 52.2% of the patients. When cough was taken as a symptom, only SI and SSI showed a poor inter-parameter association (Kendall’s tau b = 0.33, P < 0.05).

CONCLUSION: In infants investigated for suspected GERD with pH/MII-monitoring, SI, SSI and SAP showed a poor inter-parameter association and important disagreements in diagnostic classification. These limitations must be taken into consideration when interpreting the results of SAA in infants.

Clinical features and prevalence of gastroesophageal reflux disease in infants attending a pediatric gastroenterology reference service

CONTEXT: In infants, it is not always easy to distinguish between pathological and physiological gastroesophageal reflux based only on clinical criteria. In Brazil, studies about gastroesophageal reflux disease in infants are few and are even rare those that used prolonged esophageal pH monitoring for its evaluation. OBJECTIVE: To describe the clinical features of gastroesophageal reflux disease and to determine its prevalence in infants with gastroesophageal reflux attending a tertiary Pediatric Gastroenterology Service and submitted to esophageal pH monitoring for investigation. METHODS: Descriptive study in 307 infants in whom esophageal pH monitoring (Mark III Digitrapper, Synectics Medical AB, Sweden) was performed during the period December, 1998-December, 2008. The clinical features studied were age group (1-12 months and 13-24 months), and clinical manifestations that motivated the indication of pH monitoring. RESULTS: One hundred twenty-four (40.4%) were female and 183 (59.6%) male with mean age 12.2 ± 6.2 months (1-23 months). The prevalence of gastroesophageal reflux disease was 18.2% (56/307). One hundred forty-eight (48.2%) were 1-12 months old and 159 (51.8%), 13-24 months. No significant difference was found between the prevalence of these two age groups (P = 0.3006). Gastroesophageal reflux disease was more frequent in those with digestive manifestations (24.2%), crisis of cyanosis/apnea (23.8%) and mixed manifestations (21.5%). Respiratory manifestations were the most frequent indication (39.1%) of pH monitoring. However, the prevalence of gastroesophageal reflux disease was lower (12.5%) in this group compared with in those with digestive manifestations (P = 0.0574), crisis of cyanosis/apnea (P = 0.0882) and mixed manifestations (P = 0.1377). All infants that presented clinical manifestations as crisis of cyanosis/apnea and abnormal pH-metry were < 3 months of age. CONCLUSIONS: In our Service, the prevalence of gastroesophageal reflux disease associated with acid reflux in infants revealed elevated. Infants with crisis of cyanosis/apnea constitute risk population for gastroesophageal reflux disease in which diagnostic investigation needs to be considered.

Autonomic function, gastroesophageal reflux in apparent life threatening event

AIMS

To assess the autonomic function in infants with idiopathic apparent life threatening event (IALTE) with and without gastroesophageal reflux (GER) and to compare the autonomic activity in events of pure obstructive apnea and coupled events of apnea associated with GER.

METHODS

Seventeen infants diagnosed with IALTE and GER and 17 matched infants with IALTE only between the ages of 3-28 weeks participated in the study. All infants underwent a polysomnography including esophageal pH measurements. Obstructive apneas with and without associated GER were identified. Heart rate variability (HRV) was evaluated employing time domain analysis for short- and long-term variability. Forty R-R intervals for each epoch preceding, during, and following the episodes, as well as 10 segments of 40 R-R intervals unrelated to apneic episodes were analyzed.

RESULTS

A decreased baseline short-term variability among infants with IALTE and GER was found. Both short- and long-term variability were significantly increased in the period preceding the obstructive apnea when compared to the baseline values. No such autonomic activity was observed preceding coupled events of apnea and GER. While a significant increase in long-term variability following an obstructive apnea when compared to the apnea period was observed, no such changes were found following a coupled apnea-GER event.

CONCLUSIONS

Infants with history of IALTE and GER have a significant abnormality in their autonomic control that is marked in the coupled events of apnea and GER. This finding is possibly related to medullary autonomic regulation.

Recurrent acute otitis media and gastroesophageal reflux disease in children. is there an association?

OBJECTIVE

To investigate whether there is a relationship between gastroesophageal reflux disease (GERD) and recurrent acute otitis media (RAOM) in infants and children. Possible risk factors are also explored.

MATERIAL AND METHODS

221 consecutive children who had symptoms and signs associated with GERD and had undergone a prolonged ambulatory 24-h esophageal pH-monitoring. Thirty-four children were excluded from the study due to age, neurological deficits, congenital abnormalities, immunodeficiency syndromes or other chronic systemic disorders. The remaining 187 children (96 boys and 91 girls), aged between 40 days and 33 months (mean age of 18.3 months) were assigned into three groups according to their Reflux Index (RI%). Group A: 49 children (26.2%) without GERD (control group); Group B: 78 children (41.7%) with low to moderate RI; and Group C: 60 children (32.1%) with severe GERD. Parental interviews and personal medical files of the National Health System were used for data collection. However, episodes of acute otitis media were taken into account only if they were diagnosed by a physician. The follow-up period ranged from 6 to 8 years in order to cover the peaks of otitis media incidence in childhood.

RESULTS

The results revealed that 6 children from Group A (12.24%), 11 from Group B (14.1%) and 19 from Group C (31.67%) presented episodes of RAOM. The difference was statistically significant (p=0.01). Furthermore, in children who received anti-reflux treatment, the incidence of RAOM substantially decreased and eventually became approximate to that of the control Group A (12.32%). Logistic regression revealed that the strongest risk factor for recurrent otitis media was severe GERD (odds ratio, 4), then attendance at day-care centres (odds ratio, 3), followed by allergies (odds ratio, 2.7).

CONCLUSIONS

Severe GERD could be implicated in the multifactorial etiology of RAOM in infants and children.

Short-term effect of domperidone on gastroesophageal reflux in newborns assessed by combined intraluminal impedance and pH monitoring

OBJECTIVE

Neonatal gastroesophageal reflux (GER) is primarily due to a transient motility disorder and characterized by a prevalence of weakly acid refluxes. Drug management, where necessary, must set out to reduce the number of refluxes besides correct their acidity. Prokinetics could be of assistance in this respect, though the evidence in favor of their efficacy and safety is still far from sufficient. In this randomized controlled study, the action of domperidone, a prokinetic antidopaminergic drug with little effect on the central nervous system, was evaluated in newborns with symptomatic GER.

STUDY DESIGN

Combined multichannel intraluminal impedance and pH measuring for 24 h was carried out in 13 newborns receiving 0.3 mg per kg domperidone per os at the eighth and the sixteenth hour, and 13 controls. Each newborn was compared to the control nearest in postconceptional age.

RESULT

GER episodes per hour increased significantly compared to the baseline in the domperidone group (4.06+/-1.16 vs 2.8+/-1.42; P=0.001) and were shorter (16.68+/-4.49 vs 20.18+/-7.83 s; P=0.043), whereas there were no differences in the maximum proximal extent reached by the refluxes (3.37+/-0.45 vs 3.34+/-0.94 channels; P=0.894) and their pH (4.72+/-0.69 vs 4.60+/-1.17; P=0.634).

CONCLUSION

This paradoxical increase in the number of GER episodes could be the expression of a domperidone-induced amplification of the motor incoordination of the neonatal gastroesophageal tract. Doubt is thus cast on the efficacy of prokinetics in this age bracket, especially in view of their adverse effects as described in the literature.

Pharmacokinetics and acid-suppressive effects of esomeprazole in infants 1-24 months old with symptoms of gastroesophageal reflux disease

OBJECTIVES

To evaluate the pharmacokinetics and acid-suppressive effects of esomeprazole in infants with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

In this single-blind, randomized, parallel-group study, 50 infants 1 to 24 months old with symptoms of GERD, and >or=5% of time with intraesophageal pH <4 during 24-hour dual pH monitoring, received oral esomeprazole 0.25 mg/kg (n = 26) or 1 mg/kg (n = 24) once daily for 1 week. Intraesophageal and intragastric pH were recorded at 1 week, and blood samples were taken for pharmacokinetic analysis.

RESULTS

At baseline, mean percentages of time with intragastric pH >4 and intraesophageal pH <4 were 30.5% and 11.6%, respectively, in the esomeprazole 0.25 mg/kg group and 28.6% and 12.5% in the esomeprazole 1 mg/kg group. After 1 week of treatment, times with intragastric pH >4 were 47.9% and 69.3% in the esomeprazole 0.25 mg/kg and 1 mg/kg groups, respectively (P < 0.001 vs baseline), and times with intraesophageal pH <4 were 8.4% (P < 0.05 vs baseline) and 5.5% (P < 0.001 vs. baseline), respectively. The mean number of acid reflux episodes of >5 minutes duration decreased from 6 at baseline to 3 and 2 with esomeprazole 0.25 mg/kg and 1 mg/kg, respectively. The geometric mean AUC0-t of esomeprazole were 0.24 and 1.79 micromol x h/L for the 0.25 mg/kg and 1 mg/kg dosages of esomeprazole, respectively. Both esomeprazole dosages were well tolerated.

CONCLUSIONS

Oral treatment with esomeprazole 0.25 mg/kg and 1 mg/kg was well tolerated and provided dose-related acid suppression, dose-related exposure to esomeprazole, and decreased esophageal acid exposure in infants 1-24 months old with GERD.

Accuracy and tolerability of the Bravo catheter-free pH capsule in patients between the ages of 4 and 18 years

OBJECTIVE

The aim of this study was to determine if the Bravo pH capsule is comparable to the nasally placed pH catheter in terms of pH-metry, safety, and tolerability in children.

METHODS

Ten patients each in the age ranges of 4 to 6 years, 7 to 10 years, and >10 years were tested simultaneously with the catheter and the capsule. Six each were tested with the catheter alone or the capsule alone. Subjects recorded adverse events and graded tolerance (in terms of activity, appetite, and satisfaction) on a scale of 1 to 5, with a score of 5 indicating that the device was well tolerated. A 24-hour reflux index and 24- and 48-hour reflux indices were generated from the catheter and capsule, respectively. Student t test, Mann-Whitney U test, and Fisher exact test were used to compare reflux index, tolerability, and adverse events between the catheter and capsule.

RESULTS

Sixty-six patients 4 to 16 years of age (mean, 9.4 years) were enrolled. There was no statistically significant difference between the mean reflux indices (RIs) obtained simultaneously with the catheter and capsule in all patients combined on day 1 (P = 0.0665). There was a significant difference between day 2 and days 1 and 2 combined with the capsule versus the catheter (P = 0.007 and P = 0.0107); however, a discordant result of normal RI on day 1 and pathological RI on day 2 was seen in only 1 patient. The capsule was better tolerated than the catheter in terms of appetite (P = 0.029), activity (P = 0.001), and satisfaction (P = 0.003). There were no significant complications.

CONCLUSIONS

The Bravo pH capsule was as accurate and safe and better tolerated than the conventional pH catheter in children 4 years of age and older.

Acid gastroesophageal reflux in convalescent preterm infants: effect of posture and relationship to apnea

Concerns regarding gastroesophageal reflux (GER) and associated apnea episodes result in some practitioners having convalescent, prematurely born infants sleep in the prone position. We have tested the hypothesis that such infants would not suffer from clinically important acid GER or associated apnea episodes more in the supine compared with the prone position. Lower esophageal pH was measured and videopolysomnographic recordings of nasal airflow, chest and abdominal wall movements, electrocardiographic activity, and oxygen saturation were made on two successive days of 21 premature infants (median gestational age 28 wk) at a median postmenstrual age (PMA) of 36 wk. On each day, the infants were studied prone and supine. The acid reflux index was higher in the supine compared with the prone position (median 3% versus 0%, p = 0.002), but was low in both positions. The number of obstructive apnea episodes per hour was higher in the supine position (p = 0.008). There were, however, no statistically significant correlations between the amount of acid GER and the number of either obstructive or total apnea episodes in either the supine or prone position. Supine compared with prone sleeping neither increases clinically important acid GER nor obstructive apnea episodes associated with acid GER in asymptomatic, convalescent, prematurely born infants.

24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM: To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD).

METHODS: 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study, immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient, enabled to qualify children into particular study groups.

RESULTS: 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32 (12.1%) of them had CMA/FA (group 4-reference group), and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of: number of episodes of acid GER, episodes of acid GER lasting > 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed.

CONCLUSION: 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.

Eosinophilic oesophagitis and coeliac disease: is there an association?

AIM

To report a series of 17 children affected by eosinophilic oesophagitis. Six of them also received a diagnosis of coeliac disease.

METHODS

Seventeen children with history of dyspeptic symptoms were investigated.

RESULTS

Six patients (M/F:2/4; mean age +/- s.d.: 5.6 +/- 1.3 years, range: 4-7 years; Group A) affected by eosinophilic oesophagitis also received a diagnosis of coeliac disease. The other 11 children (M/F:10/1, mean age +/- s.d.:7.5 +/- 2.3 years, range: 4-10 years, Group B) were affected solely by eosinophilic oesophagitis. All children underwent a change in dietary regimen. Group A received a gluten-free diet. Group B attempted dietary restriction based on the allergy testing results. After 6 months follow-up, all patients in Group A showed a complete disappearance of symptoms and three of them, who underwent upper gastrointestinal endoscopy, showed histologic remission. Patients from Group B had moderate clinical improvement and in seven of them (64%) a repeated upper gastrointestinal endoscopy showed a statistically significant reduction in eosinophilic infiltration.

CONCLUSIONS

This is the first reported group of patients with an association between coeliac disease and eosinophilic oesophagitis. To date, it is not possible to exclude that in a subgroup of children with coeliac disease the oesophageal eosinophilic infiltration could be caused by coeliac disease itself.

Predicting internal distance to the stomach for positioning nasogastric and orogastric feeding tubes in children

AIM

This paper is a report of a study to examine how well direct morphological distances commonly used for nasogastric or orogastric tube insertion and other methods perform as predictors of the internal distance to the targeted position for the tube pores in the stomach.

BACKGROUND

Previous studies with very small samples have indicated that commonly used distances give malplacements, either above the oesophagogastric junction or below the body of the stomach, perhaps as much as 33% of the time.

METHODS

We compared the predicted distances to the endoscopic and manometric distances to the oesophagogastric junction and to the body of the stomach in a prospective study of 494 children, 2 weeks to 19 years (231 months) of age. Data were collected from 1991 to 1998 and in 2005.

RESULTS

The nose-ear-xiphoid distance commonly used in nursing, and other morphological distances, often gave estimates that were either shorter than that to the oesophagogastric junction or longer than that to the distal margin of the body of the stomach. Age-specific methods for predicting the distance to the body of the stomach based on height gave highly accurate predictions of the internal distances.

CONCLUSION

Age-specific methods have the potential to predict accurately the distances to the body of the stomach in 98.8% of children from 0.5 to 100 months of age and in 96.5% of children over 100 months of age. Where age-specific prediction methods cannot be used, the next best choice is the nose or mouth to ear-mid-xiphoid-umbilicus span.

Flexible laryngoscopy-guided pharyngeal pH monitoring in infants

OBJECTIVE

To evaluate flexible laryngoscopy-guided pharyngeal pH probe monitoring as an alternative accurate and practical pharyngeal pH probe placement technique to eliminate the need for radiographs and esophageal manometry for pharyngeal pH monitoring in infants with extraesophageal reflux disease (EERD).

MATERIALS AND METHODS

Infants with suspected laryngopharyngeal acid reflux (LPR) who underwent pharyngoesophageal pH monitoring were included. Data analysis included description of the flexible laryngoscopy-guided pharyngoesophageal pH monitoring technique and pharyngoesophageal pH monitoring findings, including the number of acid reflux episodes and percent acid exposure time.

RESULTS

Six infants (3 boys, 3 girls, age range, 2 wk-7.5 mo) with suspected LPR underwent pharyngoesophageal pH monitoring. Flexible laryngoscopy was used, under direct vision, to guide pH probe placement in the laryngopharyngeal region. The esophageal pH probe was located 5 cm distal to the pharyngeal pH probe. All infants tolerated the procedure. Of the six infants, four had pharyngeal acid reflux, and six had esophageal acid reflux. The number of acid reflux episodes ranged from 4 to 81 in the pharynx and from 5 to 173 in the esophagus. The percentage of acid exposure time was between 0% and 1.2% in the pharynx and between 0.1% and 1.5% in the esophagus.

CONCLUSION

With the aid of flexible laryngoscopy, a pH probe can be placed in the laryngopharyngeal region in infants undergoing pharyngeal pH monitoring. Findings documented that not all esophageal acid reflux reach the pharynx. Flexible laryngoscopy-guided pharyngeal pH probe placement can be used to detect LPR in infants with EERD.

Refluxo gastroesofágico em pacientes portadores de papilomatose recorrente de laringe

A cada ano aumentam as evidências de que o refluxo gastroesofágico seja um fator que contribui para as desordens de vias aéreas, principalmente na população pediátrica, podendo gerar sintomas respiratórios como estridor, tosse crônica, pneumonias de repetição e bronquite crônica. Estudos recentes têm sugerido que a associação entre papilomatose laríngea recorrente e refluxo gastroesofágico possa ser um fator determinante na recorrência e crescimento dos papilomas. OBJETIVO: O objetivo deste estudo foi verificar a freqüência e a intensidade do refluxo gastroesofágico em crianças portadoras de Papilomatose Laríngea Recorrente (PLR). MATERIAL E MÉTODOS: Foram selecionadas 10 crianças portadoras de papilomatose laríngea recorrente, de ambos os sexos, com idade entre 3 e 12 anos. Todas foram submetidas a pH-metria de 24 horas com duplo canal para avaliação da presença e intensidade de refluxo gastroesofágico. RESULTADOS: Cinqüenta por cento dos pacientes apresentaram evidências de refluxo gastroesofágico patológico em nível do esfíncter distal, e 90% apresentou refluxo proximal patológico. CONCLUSÃO: A freqüência da associação entre refluxo gastroesofágico proximal em pacientes portadores de papilomatose recorrente de laringe é extremamente alta.

Gastroesophageal Reflux in patients with Recurrent Laryngeal Papillomatosis

Evidence of a relation between gastroesophaeal reflux and pediatric respiratory disorders increases every year. Many respiratory symptoms and clinical conditions such as stridor, chronic cough, and recurrent pneumonia and bronchitis appear to be related to gastroesophageal reflux. Some studies have also suggested that gastroesophageal reflux may be associated with recurrent laryngeal papillomatosis, contributing to its recurrence and severity.

AIM

the aim of this study was to verify the frequency and intensity of gastroesophageal reflux in children with recurrent laryngeal papillomatosis.

MATERIAL AND METHODS

ten children of both genders, aged between 3 and 12 years, presenting laryngeal papillomatosis, were included in this study. The children underwent 24-hour double-probe pH-metry.

RESULTS

fifty percent of the patients had evidence of gastroesophageal reflux at the distal sphincter; 90% presented reflux at the proximal sphincter.

CONCLUSION

the frequency of proximal gastroesophageal reflux is significantly increased in patients with recurrent laryngeal papillomatosis.

Morphometric histology for infant gastroesophageal reflux disease: evaluation of reliability in 497 esophageal biopsies

OBJECTIVES

We sought to determine the reliability of morphometric measurements on infant esophageal biopsies using a light microscope with eyepiece micrometer.

METHODS

We measured epithelial thickness, basal layer thickness (B), papillary height (P) and epithelial lymphocyte and eosinophil numbers on approximately 500 existing esophageal suction biopsies from infants previously evaluated for reflux esophagitis. We tested these measurements for interobserver, test-retest and internal consistency reliability.

RESULTS

Infants ages 0.25 to 23.75 (median, 6.25) months provided 497 biopsies. Both investigators scoring the biopsies independently judged 93% of them scorable. Of the biopsies scored by both, the 2 readings were within 0.15 of each other for P in 97% and for B in 81%. In addition to these correlative measures of consistency, categoric measures demonstrated that 373 (89%) of the 420 scorable biopsies with visible papillae produced agreement as to P being abnormal (317, 85%) or normal (56, 15%). Similarly, 360 (78%) of the 463 scorable biopsies produced agreement as to B being abnormal (339, 94%) or normal (21, 6%). P values were 0.17 to 0.94 (median, 0.67), and B values were 0.13 to 0.91 (median, 0.34). Lymphocytes numbered 0 to 40 (median 5) per high-power field. Only 12% had any eosinophils; none of those with completely normal morphometrics had any eosinophils; and only 2% had >5 eosinophils per high-power field.

CONCLUSIONS

Simple quantitative esophageal histological morphometric parameters are reliably measurable on suction biopsies from infants using a light microscope fitted with an ocular micrometer, even by nonpathologists.

Increased incidence of apparently life-threatening events due to supine position

Gastro-oesophageal reflux (GOR) has a high prevalence in infancy. The supine position is among numerous aggravating factors. The exact relationship between GOR and apparently life-threatening events (ALTE) is not clear, although it has been repeatedly investigated. In 1992 the worldwide Back to Sleep campaign was implemented, which had a dramatic effect on the incidence of sudden infant death syndrome (SIDS) with a drop of 50%. Although the vast majority of children now sleep on their back, the effect of this position on ALTE has not been studied. In this retrospective study, we aim to define the potential association between GOR and ALTE. We hypothesise that the incidence of ALTE has increased since the 1992 recommendation. No bias in the population's selection was introduced, as our centre is the only one for paediatric emergencies in the county. A total of 107 children presenting with ALTE were identified during the study period (1987-99). A pH study was performed in the 75 patients presenting with ALTE in the last 6 years of the study (1994-99). Neither morbidity nor mortality was noted in a long-term 4-year follow-up. Our present results show that the frequency of ALTE increased sevenfold (P < 0.005) between 1992 and 1999. The ALTE episodes took place significantly more often in the post-prandial period. The prevalence of GOR was much higher in patients presenting with ALTE (nearly 75%) when compared with the general population. Furthermore, on medical treatment for GOR, very few patients presented with a second episode of ALTE. Consequently it is thought that GOR and ALTE are linked and that ALTE patients would benefit from GOR treatment. The worldwide marked decrease in SIDS since the implementation of the supine position possibly masks the negative effect of an increase in ALTE.

Acid and nonacid gastro-oesophageal reflux in neurologically impaired children: investigation with the multiple intraluminal impedance procedure

OBJECTIVES

The diagnosis of gastro-oesophageal reflux (GOR) is more difficult in children with neurological impairment because symptoms are often less interpretable and frequently go undetected. The use of combined pH and multiple intraluminal impedance allows for the detection of both acid (pH < 4) and nonacid (pH > 4) GOR episodes, in addition to the height of the refluxate and the total acid and bolus clearance time in this cohort.

METHODS

Sixteen neurologically impaired children (9 were fed nasogastrically, 7 were fed orally) underwent 12-hour combined pH and multiple intraluminal impedance.

RESULTS

There were a total of 425 reflux episodes during the study period, of which 239 (56.2%) were nonacid. The median of reflux episodes per hour was 1.8 (range, 0.2-6.3/h). The median height of the refluxate was 1.5 channels (range, 1.1-2.9); and 71.3% of reflux episodes reached the upper oesophagus, of which 52.4% were nonacid reflux events. On average there were more GOR events (both acid and nonacid) in the children who were fed via a nasogastric tube, and the median height of refluxate was also higher in this group. However, the median acid clearance time was longer (both proximal and distal) in the children who were fed orally (28.6 s vs 16.2 s proximally; 67.9 s vs 38.3 s distally). The median acid clearance time (21.7 s proximally; 39.5 s distally) was longer when compared with bolus clearance (14.9 s).

CONCLUSIONS

More than half of the reflux events in neurologically impaired children are nonacidic and would therefore go undetected by conventional pH metry. There are more reflux events in children fed nasogastrically than oral-fed children.

The relationship between somatic growth and in vivo esophageal segmental and sphincteric growth in human neonates

BACKGROUND

Measurement of aerodigestive tract length is an important determinant for accurate placement of esophageal probes and gavage tubes at the desired location. The relationship of esophageal body, upper esophageal sphincter (UES) and lower esophageal sphincter (LES) lengths with somatic growth in neonates is not well understood.

OBJECTIVES

Our objectives were to (1) evaluate a relationship between segmental esophageal lengths and somatic growth parameters and (2) ascertain the relationship between segmental esophageal lengths and gestational age (GA) and postmenstrual age (PMA) in preterm and full-term born human neonates.

DESIGN/METHODS

One hundred esophageal manometry studies were performed in 75 infants (30-60 weeks PMA) and the high-pressure zones of LES and UES identified. The distance from nares to LES and from nares to UES, esophageal body length, length of UES and LES derived from the manometry studies were correlated with somatic growth parameters. Growth rate of different esophageal segments was also determined in 26 subjects that underwent longitudinal studies. Analysis of variance and linear regression analysis were performed.

RESULTS

Seventy-five neonates of 23.0-40.6 weeks gestational age (0.6-4.4 kg) were studied at 29.1-58.6 weeks PMA (1.0-6.4 kg). Significant correlation (P < 0.001) of PMA and physical growth parameters with the growth of nares-LES (R = 0.8), esophageal body length (R = 0.6) and nares-UES (R = 0.4) were noted. Nares-to-LES length increased at a rate of 0.25 cm/wk PMA during 33.0-36.0 weeks of age.

CONCLUSIONS

In vivo esophageal segmental lengths correlated strongly with somatic growth parameters and PMA in neonates. We speculate that this approach has many practical applications with the use of esophageal probes and catheters.

Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis

OBJECTIVES

Basal cell hyperplasia of the esophageal epithelium is a frequent finding in children with histological evidence of esophagitis. The aim of this study was to compare the severity of basal cell hyperplasia in gastroesophageal reflux vs eosinophilic esophagitis.

METHODS

A cohort of pediatric patients who underwent same-day endoscopy with esophageal biopsy and 24-hour esophageal pH monitoring was divided into groups based on endoscopic and pH monitoring findings. Basal cell hyperplasia was defined as normal (< or = 25% of esophageal epithelial height), mild (26%-50%), moderate (51%-75%) or severe (> 75%). The severity of basal cell hyperplasia in patients with abnormal pH monitoring studies, both with and without endoscopic abnormalities of the esophagus, was compared with the severity in patients with eosinophilic esophagitis.

RESULTS

Twenty-seven children with abnormal pH monitoring were identified. Of these 27 children, 11 had endoscopic findings consistent with reflux esophagitis. Thirty patients with eosinophilic esophagitis were identified. Patients with eosinophilic esophagitis had significantly increased severity (P < 0.001) of basal cell hyperplasia (87% severe, 3% moderate, 3% mild, 7%, normal) than patients with abnormal esophageal pH monitoring alone (11% severe, 4% moderate, 15% mild, 70% normal) or in combination with endoscopic abnormalities (18% severe, 9% moderate, 18% mild, 55% normal).

CONCLUSIONS

Basal cell hyperplasia is more severe in children with eosinophilic esophagitis than in those with reflux esophagitis. The finding of basal cell hyperplasia is a powerful clue into the underlying etiology of pediatric esophagitis and, along with epithelial eosinophil count, can be used as information to guide therapy.

Relationship between gastro-oesophageal reflux and gastric activity in newborns assessed by combined intraluminal impedance, pH metry and epigastric impedance

The pathogenesis of gastro-oesophageal reflux disease (GORD) is complex and multifactorial. A motility disorder resulting from immaturity of the gastro-oesophageal tract may be involved. We have combined multichannel intraluminal impedance (MII) and pH monitoring with epigastric impedance (EGI) to evaluate the activity of this tract in neonates with suspected GORD. Multichannel intraluminal impedance, pH and EGI were followed for 3 h in 30 newborns displaying apparent life-threatening events and signs of GORD. Simultaneous application of MII and pH monitoring identifies reflux episodes and illustrates their duration, height and pH. Episodes detected by MII were placed on the EGI curve and the contemporaneous gastric filling state and emptying velocity were calculated. During the total measuring time, 248 reflux episodes were revealed. An inverse correlation was evident for reflux frequency and gastric emptying velocity (r2 = 0.94; P < 0.001), and between acid refluxes and the gastric filling state (r2 = 0.95; P < 0.001), whereas a positive correlation was found between the reflux level and the gastric filling state (r2 = 0.52; P < 0.05). Simultaneous MII, pH and EGI monitoring provided new information on the relationship between refluxes and gastric activity. Data suggest that gastric emptying patterns influence the frequency, level and pH of reflux episodes.

Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal.

AIMS

To examine the diagnostic accuracy of clinical predictors of pathological GOR in infants with persistent crying.

METHODS

One hundred and fifty-one infants (82 male; median age 2.5 months, range 0.5-8.2 months) with persistent crying were prospectively studied. Crying and fussing were charted for 24 h, and parents completed a validated questionnaire on reflux symptoms. All infants underwent oesophageal 24-h pH monitoring.

RESULTS

Twenty-seven (17.9%) infants had pathological GOR with a fractional reflux time (FRT) >10%. There was no significant association between total crying duration per 24 and FRT (P = 0.84) or the number of reflux episodes (P = 0.68). Pathological GOR was more common in infants under 3 months, compared to older infants (P = 0.04). Feeding difficulties were significantly associated with pathological GOR (P = 0.02). Backarching was not increased in infants with GOR (P = 0.30). Pathological GOR was significantly associated with the frequency of regurgitation (P = 0.04), but not with vomitus volume (P = 0.62). Regurgitation more than 5 times daily was the most specific reflux symptom (specificity 70.9%), but was a poor predictor of pathological GOR (positive predictive value 22.2%). In the absence of frequent regurgitation or feeding difficulties, pathological GOR was unlikely (negative predictive value 87-90%).

CONCLUSIONS

Investigation and treatment of GOR in infants with persistent crying should be primarily directed at infants presenting with frequent regurgitation or feeding difficulties.

Natural history of infant reflux esophagitis: symptoms and morphometric histology during one year without pharmacotherapy

OBJECTIVES

To determine the natural history of infant gastroesophageal reflux disease (GERD) with esophagitis, we periodically analyzed symptoms and biopsies during 1 yr in 19 infants randomly assigned to placebo in a pharmacotherapy study.

METHODS

One hundred infants who were referred during 1994-1999 for GERD, were unresponsive to 2-wk life-style measures, and manifested morphometric reflux esophagitis, were assigned at random to one of four treatment arms. This analysis examines the 19 (ages 2.8-6.0 months) assigned to placebo who returned for initial follow-up. SYMPTOMS and esophageal biopsy were assessed at baseline and 2, 4, 6, and 12 months. At any visit with both symptoms and biopsy unimproved, infants were "rescued" to open label active drug.

RESULTS

By 12 months, 10/19 completed without rescue; the 9 others withdrew (3) or required pharmacotherapy (6).

SYMPTOMS

Among the 10 nonrescued completers, parents' global score rated 9 "completely well," and 1 "improved." Comparing 12-month symptoms to baseline symptoms in the 10 completers, fewer reported regurgitation >3/day, >1 Tbsp, or that was uncomfortable; crying >1 h/d, or during or after feeds; or arching spells or abnormal hiccups (p < 0.05, chi(2)). Biopsy: None of the 10 ever had normal biopsies (basal cell layer <25% and papillary height <53% of epithelial thickness). One had normal papillary height, but abnormal basal thickness. Five others had normal basal thickness, but all five of them had abnormal papillary height.

CONCLUSION

Although symptoms improved in more than half of the infants with reflux esophagitis followed longitudinally for 1 yr without pharmacotherapy, histology remained abnormal.

Nocturnal acid breakthrough in children with reflux esophagitis taking proton pump inhibitors

OBJECTIVES

We aimed to determine if nocturnal acid breakthrough occurs in children receiving proton pump inhibitors for reflux esophagitis, and to compare the healing of esophagitis in children with nocturnal acid breakthrough receiving proton pump inhibitors +/- ranitidine.

METHODS

This is a prospective, double-blind study. Endoscopic and histologic esophagitis were scored 0-4 and 0-3, respectively. Patients were treated with a proton pump inhibitor twice daily and esophagogastric pH monitoring was performed at week 3. Patients with nocturnal acid breakthrough were randomized. One group received ranitidine and the other received placebo at bedtime in addition to proton pump inhibitor therapy. Endoscopy was performed on all patients (with pH monitoring on patients with nocturnal acid breakthrough) during the 17th week of therapy.

RESULTS

We enrolled 18 patients, ages 1 to 13 years (mean = 10.3 years). Mean baseline endoscopic and histologic scores were 3.1 +/- 1.4 and 1.8 +/- 0.7, respectively. Mean dose of proton pump inhibitor was 1.3 mg/kg +/- 0.6. Nocturnal acid breakthrough was documented in 16/18 (89%) patients. Seven patients received ranitidine and 9 received placebo. The reflux index improved: mean of 14.3 at baseline, 2.0 at week 3 (P = 0.0001), and 5.1 at week 17 (P = 0.09). Nocturnal acid breakthrough persisted in 9/12 (75%) patients, 3 of whom received ranitidine at bedtime. Esophagitis improved in all patients following therapy: mean endoscopy and histology scores were 1.6 +/- 1.8 (P = 0.0020) and 0.8 +/- 0.9 (P = 0.0013), respectively. Symptoms significantly improved from a mean score of 2.0 at baseline to 0.4 at week 17 (P = 0.0001).

CONCLUSIONS

Nocturnal acid breakthrough is common in pediatric patients treated with proton pump inhibitors. Reflux index remains normal in spite of nocturnal acid breakthrough. Symptoms and esophagitis continued to improve during therapy in spite of nocturnal acid breakthrough. There appears to be no additional benefit to supplementation with ranitidine at bedtime.

Effect of antireflux medication, placebo and infant mental health intervention on persistent crying: a randomized clinical trial

OBJECTIVE

To assess the effect of medical antireflux treatment, and of an infant mental health consultation (IMHC), on persistent crying in infants and maternal distress.

METHODS

Infants under 9 months of age with persistent crying, and their mothers, were enrolled in a randomized placebo-controlled trial. At enrollment, a questionnaire on demographic and clinical details was completed by mothers, and maternal distress was measured (Experience of Motherhood Questionnaire; EMQ). Oesophageal 24-h pH monitoring was performed in all infants on day 2. At week 4, the cry chart and EMQ were repeated in conjunction with a final interview.

RESULTS

One hundred and three infants (56 under 3 months of age; 55 male) who were randomized to active medication (ranitidine plus cisapride; n = 34), placebo (n = 29) or IMHC (n = 40) completed the trial. There was a significant reduction in crying duration from baseline to week 4 (253 +/- 96.5 min vs 159 +/- 92.3 min per 24 h; P < 0.001), without differences between treatment groups (AVOVA: F = 0.75; P = 0.48). There was a modest improvement in EMQ scores from 44.9 +/- 8.6 at day 1 to 42.8 +/- 9.4 at week 4; P = 0.006. The improvement in maternal stress was similar in all treatment groups (Kruskal-Wallis chi2 = 0.354; P = 0.84), but subsequent admission to a mother-infant unit was significantly less frequent in the IMHC group (P < 0.05).

CONCLUSION

Antireflux medications and IMHC were not superior to placebo in treating infants with persistent crying. Although the reduction in maternal distress was similar in all treatment groups, the individualized IMHC reduced the need for subsequent admission to a mother-infant unit.

[Esophageal pH monitoring study of eight hours in pediatric patients with suspected gastroesophageal reflux]

PURPOSE

To study the pH monitoring over eight hours, analyzing variables such symptomatology and esophagogastroduodenoscopy, as well as the following pH monitoring parameters: number of reflux episodes, number of episodes longer than five minutes, length of reflux time during the eight hours, and the episode of longest duration, for the diagnosis of gastroesophageal reflux.

METHODS

A prospective study. Continuous measurement of esophageal pH was performed over eight hours on 35 patients whose ages ranged from four months to 11 years. The DPS-100 Diagnosis pH meter System was utilized, programmed in accordance with the methodology suggested by Vandenplas. The pH monitoring results were divided into positive and negative and compared with all the variables and parameters of the examination.

RESULTS

We obtained statistically significant differences in all the pH monitoring parameters analyzed, with the reflux index being the most effective for identifying the pathological reflux, independent of age. None of the qualitative variables of age, symptomatology and esophagogastroduodenoscopy showed statistically significant differences when compared to the pH monitoring results.

CONCLUSION

The esophageal pH monitoring of eight hours has its pH monitoring parameters validated for the diagnosis of gastroesophageal reflux.

Myoelectrical activity of the stomach after surgical correction of esophageal atresia

AIM

The aim of this study was to investigate the motor activity in the stomach of infants with repaired esophageal atresia (EA).

METHOD

Gastric myoelectrical activity was investigated by cutaneous electrogastrography in 15 infants after the surgical correction of EA. Ten infants with no gastrointestinal upset served as controls. Studies were done before and after a milk feed. The pH of the lower esophagus was measured for 24 hours to assess the gastroesophageal reflux (GER) in the infants with repaired EA.

RESULTS

After feeding, a significant increase in bradygastria and decrease in tachygastria were observed as compared with the preprandial period. Compared with healthy infants, the electrogram showed pathological patterns in 73.3% (11/15) of EA patients. Twelve of 15 EA patients showed some clinical sign of GER, and 60% of the EA patients proved to be GER-positive on esophageal pH monitoring. There was no difference in the distribution of gastric myoelectrical waves between the GER-positive and GER-negative EA patients either before or after meal.

CONCLUSION

Cutaneous electrogastrography is a noninvasive, harmless method for obtaining indirect information about the motor function of the stomach. The abnormal changes in physiological gastric myoelectrical activity in EA patients can serve as markers of disturbed neuromuscular function and can play a role in the pathogenesis of feeding disturbances after operative correction of EA. Gastroesophageal reflux, which often occurs after surgical repair of EA, seems to be connected not only with disordered gastric myoelectric activity, but also probably with other factors such as artificially straightened esophagogastric angle or brachyesophagus.

Hypopharyngeal and distal esophageal pH monitoring in children with gastroesophageal reflux and respiratory symptoms

PURPOSE

Fundoplication is frequently required for gastroesophageal reflux (GER)-related respiratory disease. Correlation between esophageal pH data and respiratory symptoms is poor but may be improved by monitoring hypopharyngeal pH. Reflux to the hypopharynx is underestimated by salivary bicarbonate. The aim of this study was to determine if hypopharyngeal pH monitoring using pH 4 and pH 5 as reflux thresholds could predict children with reflux-related respiratory disease.

METHODS

One hundred five children aged 4 months to 12 years underwent esophageal and hypopharyngeal pH monitoring. Hypopharyngeal pH data were analyzed using pH 4 and pH 5 as reflux thresholds. pH data from 4 groups were compared: group A, control group, no GER, no respiratory symptoms (n = 20); group B, respiratory symptoms, no GER (n = 16); group C, GER, no respiratory symptoms (n = 26); and group D, both GER and respiratory symptoms (n = 37).

RESULTS

Comparing groups C and D, there was no significant difference in hypopharyngeal pH data. Using pH 5 as the reflux threshold, children in group B refluxed to the hypopharynx significantly more frequently than controls. This was most evident in children with wheeze.

CONCLUSION

Hypopharyngeal pH monitoring does not differentiate children with GER and respiratory symptoms from those with GER alone and is therefore of doubtful value in diagnosing recurrent aspiration.

Ethnicity and gender related differences in extended intraesophageal pH monitoring parameters in infants: a retrospective study

Background

Gastroesophageal reflux disease (GERD) is believed to be more common in adult males as compared to females. It also has been shown in adults to be more common in Caucasians. We wanted to determine ethnicity and gender related differences for extended pH monitoring parameters in infancy.

Methods

Extended pH monitoring data (EPM) from infants <1 year of age were reviewed. Results were classified in two groups, as control and Gastroesophageal reflux disease (GERD) group based on the reflux index (RI). The GERD group had RI of equal to or more than 5% of total monitoring period. The parameters of RI, total number of episodes of pH < 4, and the number of episodes with pH < 4 lasting more than 5 minutes were compared by genders and by ethnic groups, Caucasians and African American (AA).

Results

There were 569 infants, 388 controls, 181 with GERD (320 males, 249 females; 165 Caucasians, 375 AA). No statistical difference in EPM parameters was detected between genders in both groups. However, Caucasian infants had a significantly higher incidence of GERD than AA infants (p = 0.036). On stratifying by gender, Caucasian females had a significantly higher number of reflux episodes >5 minutes as compared to AA females in the control group (p = 0.05). Furthermore, Caucasian females with GERD showed an overall higher trend for all parameters. Caucasian males had a trend for higher mean number of reflux episodes as compared to AA males in the control group (p = 0.09).

Conclusion

Although gender specific control data do not appear warranted in infants undergoing EPM, ethnic differences related to an overall increased incidence of pathologic GERD in Caucasian infants should be noted.

Predicting the insertion distance for placing gastric tubes

Approximately 1 million enteral tubes are placed through the nose or mouth in adults and children in the United States annually. Previous studies found gastric tube placement errors to be common. A primary issue in ensuring safe and effective gastric feeding by tube is achieving optimal tube position on insertion. The purpose of this study is to use 24 variables to develop a clinical prediction rule for gastric tube insertion distance in adults, using the internal-nares-to-distal-lower esophageal-sphincter distance. A three-variable model using gender, weight, and nose-umbilicus-flat was selected. This new model, validated using nonparametric bootstrap cross-validation, correctly predicted gastric tube insertion distance 85.3% of the time. This new model is compared to two other methods, one evidence based and one commonly used in practice, and was found to be superior. Two nomograms, one for each gender, are drawn to make this new model easier to use.

Diagnostic interpretation of extended pH monitoring: is there a single best method?

Our aims were to compare the specificity and sensitivity of the reflux index (RI), Euler and Byrne score (EBS), and area under the curve (AUC) at pH < 4.0 in infants 1 year old for identifying pathologic gastroesophageal reflux (GER) and to identify new cutoffs on formula feedings. We undertook a prospective investigation of extended pH monitoring (EPM) in 117 infants with symptoms of GER. Infants were categorized as having pathologic reflux by three measures: RI > or = 5%, EBS > or = 50, or AUC pH < 4.0 or < or = 21.3, as determined by receiver operating characteristic (ROC) curve analysis. Using the RI as a criterion, 27 infants (23%) had pathologic reflux. When EBS and AUC were used, 65 (56%), and 67 (57%) respectively, were classified as having pathologic reflux. The specificities of RI, EBS, and AUC were 97.8, 100.0, and 100.0%, respectively, and the sensitivities were 93.0, 91.5, and 94.4, respectively. A new cutoff value for RI of 2.1% was determined using ROC curve analysis to improve the specificity and sensitivity of RI to the above values. The number of infants with pathologic GER is likely to be significantly less using the traditional RI alone on formula feedings, however, the revised RI cutoff value and AUC analysis by computerized pH tracings can enhance the accuracy on formula feedings.

Severe gastroesophageal reflux disease and cow milk hypersensitivity in infants and children: disease association and evaluation of a new challenge procedure

BACKGROUND

Gastroesophageal reflux disease (GERD) and cow milk hypersensitivity are frequent disorders of infancy. A possible causative association between these two entities has been suggested.

OBJECTIVE

The primary aim was to elucidate whether a causative relationship between the two entities could be established in a population of infants and children. A secondary aim was to evaluate whether cow milk challenge during esophageal pH monitoring is useful as an objective method to identify this subgroup of patients.

METHODS

Upper endoscopy followed by a 48-hour esophageal pH monitoring with cow's milk elimination diet at day 1 and challenge at day 2. Cow milk hypersensitivity was later verified by elimination diet and a second open (in patients < 3 years of age) or double-blind placebo-controlled (in patients > or = 3 years of age) challenge. Skin prick test, specific serum immunoglobulin E and skin patch test were used as supplementary procedures. Follow-up endoscopy and pH monitoring were performed after 3 months of treatment (omeprazole versus elimination diet dependent on evidence of food hypersensitivity).

RESULTS

Eighteen of 42 investigated patients had severe GERD, defined as endoscopic esophagitis and/or a reflux index > 10%. Among these patients, a group of 10 patients with GERD and cow milk hypersensitivity was identified. This group had a significantly higher reflux index compared with children with primary GERD. No significant increase was noted in reflux index during simultaneous pH monitoring and milk challenge.

CONCLUSIONS

An association between GERD and cow milk hypersensitivity was observed in both infants and children with severe GERD. Simultaneous cow milk challenge and pH monitoring had limited value as a method to identify this subgroup.

Gastroesophageal reflux disease beyond infancy

BACKGROUND

Children beyond infancy (>12 months of age) rarely have gastroesophageal reflux disease (GERD). Underlying diseases may contribute to the persistence of GERD from infancy to childhood. This study compares the clinical course of children with GERD with and without underlying diseases.

METHODS

The authors studied the role of underlying diseases responsible for GERD in children beyond infancy by a retrospective analysis. From 1985 to 2000, GERD was confirmed in 34 children beyond infancy in the National Taiwan University (median age 2.5 years, range 1.1-9.7 years), according to the inclusion criteria of reflux symptoms and the fraction of pH < 4 above 5% in the 24-h esophageal pH study. The patients were divided into two groups: those without underlying diseases (n=10) and those with underlying diseases (n=24). The follow-up duration was 0.5-17.1 years (median 4.5 years).

RESULTS

The underlying diseases responsible for GERD in 24 children included neurological impairment (n=14), repaired esophageal atresia (n=2), hiatal hernia (n=3), repaired congenital diaphragmatic hernia (n=2), and congenital heart disease (n=3). At the end of the study, 9 of 10 children with GERD beyond infancy and without underlying diseases were free of symptoms without any need for further medical treatment. In contrast, 10 of 14 children with neurological disorders had persisting reflux symptoms (Kaplan-Meier analysis, P=0.02, log-rank test).

CONCLUSIONS

Neurological impairment and esophageal or diaphragmatic anatomic abnormalities were frequently associated with GERD beyond infancy. Children with underlying diseases, especially with neurological impairment, ran a refractory course, while those without underlying diseases enjoyed a longer symptom-free life.

Gastric emptying in children with cerebral palsy and gastroesophageal reflux

Gastric emptying time is considered a factor in the increased frequency of gastroesophageal reflux in children with cerebral palsy. It is unknown if emptying time influences the severity of reflux. In this study, 76 cerebral palsy patients with reflux indicative symptoms were investigated by 24-hour pH monitoring. Reflux complications were also studied. Emptying time in children with reflux was investigated using gastric scintigraphy. Twenty-eight children with resistant asthma scanned for pulmonary aspiration were studied as control subjects for emptying time. Reflux was diagnosed in 51.3%; it was severe in 53.8%, moderate in 38.5%, and mild in 7.7%. Occurrence of reflux did not differ significantly among different forms of cerebral palsy or between males and females. The most frequent complications in reflux-positive patients were iron deficiency (51.3%), anemia (41.0%), malnutrition (33.3%), recurrent upper respiratory tract infections (28.2%), and low body weight (28.2%). Patients without reflux had less frequent complications. Gastric emptying time measured by gastric scintigraphy in 28 patients with reflux manifested no difference in comparison to the control group (P > 0.05). No relationship was found between emptying time and reflux severity (P > 0.05). In conclusion, reflux (moderate or severe) is common in children with cerebral palsy, frequently leading to complications but no delayed emptying time. The patients described in this report had no delayed emptying time. There was also no relationship between emptying time and severity of reflux.

Chest physiotherapy, gastro-oesophageal reflux, and arousal in infants with cystic fibrosis

BACKGROUND

Postural drainage chest physiotherapy in infants with cystic fibrosis (CF) exacerbates gastro-oesophageal reflux (GOR) and may contribute to a more rapid deterioration in lung function.

AIMS

To compare standard postural drainage chest physiotherapy (SPT) and a modified physiotherapy regimen (MPT) without head-down tilt, with regard to GOR, arousal state, and cardiorespiratory function.

METHODS

Twenty infants with CF underwent 30 hour oesophageal pH monitoring, during which four chest physiotherapy sessions were administered (day 1: MPT-SPT; day 2: SPT-MPT). Arousal state, heart rate, and oxygen saturation were documented for each of the physiotherapy positions (supine, prone, right lateral, and left lateral with (SPT) or without (MPT) 30 degrees head-down tilt).

RESULTS

Significantly more reflux episodes occurred during SPT than during MPT, but there were no significant differences in median episode duration or fractional reflux time. During SPT, left lateral positioning was associated with fewer reflux episodes compared to other positions. During supine and prone positioning, more reflux episodes occurred during SPT than during MPT. Infants were significantly more likely to be awake or cry during SPT. There was a significant association between crying and reflux episodes for SPT. Non-nutritive sucking was associated with a significant reduction in reflux episodes during SPT. Oxygen saturation during SPT was significantly lower during crying and other waking, and non-nutritive sucking during SPT was associated with a significant increase in oxygen saturation.

CONCLUSIONS

SPT is associated with GOR, distressed behaviour, and lower oxygen saturation.

Correlation between number of eosinophils and reflux index on same day esophageal biopsy and 24 hour esophageal pH monitoring

OBJECTIVES

The presence of eosinophils on esophageal biopsy is a marker of esophagitis in children. Eosinophilic inflammation without evidence of gastroesophageal reflux has led to the new diagnosis of eosinophilic, or allergic, esophagitis. The aim of this study was to correlate the number of eosinophils with the reflux index on same day esophageal biopsy and 24 h esophageal pH monitoring.

METHODS

A retrospective analysis of data collected from children who underwent same day endoscopy with esophageal biopsies and 24 h esophageal pH monitoring over a 3-yr period was performed. The patients were divided into five groups: Group 1: 0 eosinophils/hpf and no histologic change, Group 2: 0 eosinophils/hpf but histologic changes, Group 3: 1-5 eosinophils/hpf, Group 4: 6-20 eosinophils/hpf, and Group 5: >20 eosinophils/hpf. Reflux indices were analyzed within each group.

RESULTS

A total of 305 patients met the inclusion criteria. The mean reflux indices +/- standard error within each group were Group 1 (n = 171): 2.14 +/- 0.18%, Group 2 (n = 40): 3.93 +/- 1.24%, Group 3 (n = 42): 5.96 +/- 1.53%, Group 4 (n = 21): 4.18 +/- 1.27%, and Group 5 (n = 31): 2.02 +/- 0.53%. The mean reflux index in Group 3 was significantly greater than Groups 1 and 5.

CONCLUSIONS

The presence of denser infiltrates of eosinophils does not correlate with increased gastroesophageal reflux. The finding of more than 20 eosinophils/hpf is likely associated with a normal reflux index and a nonacid-related cause of esophagitis.

Variability of the Carina–Incisor Distance as assessed by Endoscopic Ultrasound

AIM

The purpose of this study is to demonstrate variability of the carina-incisor distance (CID), and define morphological factors associated with this.

MATERIALS AND METHODS

The carina is clearly visualised on endoscopic ultrasound (EUS), and the CID was measured in 50 patients (29 men, 21 women) undergoing EUS for various indications (30 oesophageal cancer, 20 other) with Olympus UM-20 (used in 24 cases) or MH-908 (used in 26 cases) radial echoendoscopes. Patient height and weight were compared with CID using Pearson's correlation coefficient.

RESULTS

Mean CID was 25.7 cm, with a range of 20.5-29 cm (SD +/- 1.99). There was no difference between the measured CID in the oesophageal cancer and non-oesophageal cancer groups, or between the two types of echoendoscope. There was highly significant positive correlation between patient height and CID (r = +0.750; P < or = 0.01).

CONCLUSION

This study demonstrates considerable variability of the CID from 20.5-29 cm. It is no longer appropriate to assume a 'normal' carinal level of 25 cm in all patients. In this study, if the carina was accepted to lie at 25 cm, this would have led to radiation therapy missing macroscopic disease, a so called 'geographic miss', in nine of the 50 (18%) patients. We now routinely record the level of the CID, the upper and lower extent of the primary tumour and lymph-node metastases with reference to the incisor teeth. This is simple to perform and may assist in radiotherapy planning by reducing the geographic miss rate.

Esophageal eosinophilia in children with dysphagia

OBJECTIVES

Children occasionally have dysphagia in the absence of an apparent primary cause. Esophageal eosinophilia is sometimes seen in these patients at the time of upper endoscopy but its significance is not clear. Although eosinophilia is regarded by some as a histologic hallmark of childhood reflux esophagitis, it may in fact signal a primary eosinophilic esophagitis in children with dysphagia. Our aim was to evaluate esophagitis, acid reflux determined by pH probe, and esophageal eosinophilia in children with the primary complaint of dysphagia.

METHODS

A retrospective study was performed in 42 children, admitted for investigation of dysphagia, in whom no primary cause could be found. Twenty-one children (mean age +/- SD, 10.1 +/- 4.0 years) had esophageal eosinophilia and 21 children (8.3 +/- 4.7 years) did not. Clinical, endoscopic, manometric and esophageal pH parameters in these two groups were compared.

RESULTS

Patients with esophageal eosinophilia were more often male (p<0.01) with a history of allergy (p<0.001) and food bolus obstruction (p<0.05) requiring endoscopic removal. Their esophageal mucosa appeared wrinkled and thickened at endoscopy with basal cell proliferation, and large numbers of eosinophils in esophageal mucosal biopsies. Continuous esophageal pH records and motility studies, when obtained, were similar in both groups and were within normal values.

CONCLUSION

Children with dysphagia who have esophageal eosinophilia are unlikely to have pathologic gastroesophageal reflux.

Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux

OBJECTIVE

To assess the efficacy of omeprazole in treating irritable infants with gastroesophageal reflux and/or esophagitis.

STUDY DESIGN

Irritable infants (n=30) 3 to 12 months of age met the entry criteria of esophageal acid exposure >5% (n=22) and/or abnormal esophageal histology (n=15). They completed a 4-week, randomized, double-blind, placebo-controlled crossover trial of omeprazole. Cry/fuss diary (minutes/24 hours) and a visual analogue scale of infant irritability as judged by parental impression were obtained at baseline and the end of each 2-week treatment period.

RESULTS

The reflux index fell significantly during omeprazole treatment compared with placebo (-8.9%+/-5.6%, -1.9%+/-2.0%, P<.001). Cry/fuss time decreased from baseline (267+/-119), regardless of treatment sequence (period 1, 203+/-99, P<.04; period 2, 188+/-121, P<.008). Visual analogue score decreased from baseline to period 2 (6.8+/-1.6, 4.8+/-2.9, P=.008). There was no significant difference for both outcome measures while taking either omeprazole or placebo.

CONCLUSIONS

Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability. Irritability improved with time, regardless of treatment.

The effects of common airway maneuvers on airway pressure and flow in children undergoing adenoidectomies

Obstruction of the upper airway occurs frequently in anesthetized, spontaneously breathing children, especially in those with adenoidal hyperplasia. To improve airway patency, maneuvers such as chin lift (CL), jaw thrust (JT), and continuous positive airway pressure (CPAP) are often used. In this study, we examined the comparative efficacy of these maneuvers in children scheduled to undergo adenoidectomy. Sixteen children aged 2-9 yr were anesthetized with sevoflurane. During spontaneous breathing, the flows and pressures in the mask (ma), oropharynx (op), and esophagus (es) were measured simultaneously, and maximal pressure differences during inspiration (DeltaP) were calculated. After baseline recording, CL and JT maneuvers were performed in random order without and with CPAP (5 cm H(2)O). The observed DeltaP(ma) - P(es) of 12.3 +/- 3.4 cm H(2)O at baseline decreased with all airway maneuvers (P < 0.05). This resulted from decreases of DeltaP(ma) - P(op) (P < 0.05) and DeltaP(op) - P(es) (P < 0.05) in all interventions except CL, in which DeltaP(ma) - P(op) remained similar. In contrast, significant improvements of minute ventilation and maximal inspiratory peak flow (P > 0.05) were observed only with JT (with and without CPAP). We conclude that CL may improve airway patency and ventilation, whereas JT with or without CPAP was the most effective maneuver to overcome airway obstruction in children with adenoidal hyperplasia.

IMPLICATIONS

Airway maneuvers are often used in anesthetized children to relieve airway obstruction during spontaneous ventilation. Compared with chin lift and continuous positive airway pressure, the jaw thrust maneuver was the most effective to improve airway patency and ventilation in children undergoing adenoidectomy.

Optimizing the diagnosis of gastroesophageal reflux in children with otolaryngologic symptoms

OBJECTIVES

Although many children with otolaryngologic (ENT) symptoms are being treated for gastroesophageal reflux (GER), how to diagnose GER in children with primarily or exclusively ENT symptoms has yet to be determined. This study compares the incidences of pathologic GER in the upper verses the lower esophagus in a cohort of children with ENT symptoms that were screened for GER.

METHODS

The results of extended dual channel intraesophageal pH probe monitoring obtained from 14 infants and 14 children with ENT symptoms were retrospectively analyzed. The percent of total monitoring time that the pH was less than 4, reflux index (RI) was determined. The upper limits of normal distal and proximal esophageal RI were based on published data. To evaluate our results, upper esophageal reflux (UER) was also determined in 27 infants and children without ENT or pulmonary symptoms, who had normal lower esophageal reflux (LER) values.

RESULTS

Mean upper esophageal RIs in the infants and children with normal LER were similar to previously published values for control infants and adults. Four (29%) of the ENT infants, 11 (79%) of the older ENT children, and 54% of the entire cohort had increased esophageal acid exposure. However, nine (60%) of the 15 pediatric ENT patients with GER had pH abnormalities limited to the upper esophagus.

CONCLUSIONS

Standard distal pH probe monitoring alone gives a false negative result in a substantial proportion of the infants and children with ENT symptoms being evaluated for GER. Beyond its value in clinical practice, UER testing should be employed in research studies that evaluate the impact of GER therapy on ENT symptoms.